Neurology Asia

Neurointervention rotations and comfort with clinical decision-making in stroke and neurocritical care: A nationwide survey of Indonesian neurology trainees

Achmad Firdaus Sani — 2026-06-07

Background & Objective: Cerebrovascular diseases are among the most frequently managed conditions in neurology residency. With advances in reperfusion and endovascular therapies, exposure to neurointervention has become increasingly relevant in residency training. However, neurointervention rotations are not uniformly implemented across Indonesian training centers. This study aimed to explore neurology trainees’ perspectives on neurointervention rotations and to evaluate whether participation in such rotations influences comfort with clinical decision-making in stroke and neurocritical care.

Methods: An electronic survey was distributed in early 2025 to 15 neurology residency training centers across Indonesia. Neurology trainees were randomly selected from each participating center to complete the questionnaire. The survey, adapted from previous studies, assessed demographics, exposure to neurointervention, and comfort with clinical decision-making using a five- point Likert scale. All responses were collected anonymously to ensure confidentiality.

Results: Of 120 invited residents, 116 (96.7%) completed the survey. Neurointervention rotations were offered at 11 centers, completed by 66 (56.9%) respondents. Most trainees (83.6%) believed such rotations should be mandatory. Residents who had completed a neurointervention rotation reported significantly greater comfort in identifying large vessel occlusion (p=0.003), interpreting cerebral angiograms (p<0.001), determining Thrombolysis in Cerebral Infarction score (p=0.018), and managing intracerebral and subarachnoid hemorrhage in stroke units (p=0.02).

Conclusion: Neurovascular and neurocritical care rotations provide a foundation for clinical decision- making in stroke. However, dedicated neurointervention rotations significantly improve trainees’ comfort in managing hyperacute stroke and neurointervention-related cases, and may also encourage pursuit of fellowship training. Standardizing such rotations across training centers could better prepare residents for the complex decision-making required in modern stroke and neurocritical care.

Mycoplasma hominis central nervous system infection diagnosed by metagenomic next- generation sequencing: A case report

Shaoqi Wu — 2026-06-07

Mycoplasma hominis (M. hominis) is a rare cause of intracranial infection with diagnostic challenges due to its fastidious nature, nonspecific symptoms mimicking common nervous system infection (e.g., viral encephalitis), and absence of characteristic neuroimaging. Traditional methods (culture/ serology) often yield false negatives, delaying appropriate therapy. Metagenomic Next-Generation Sequencing (mNGS) provides an unbiased solution for such pathogens. We report a 50-year-old male presented with recurrent fever and coma after hematoma evacuation and external ventricular drainage for cerebral hemorrhage. Empirical antimicrobial therapy (ceftriaxone → piperacillin-tazobactam → vancomycin) was ineffective. Cerebrospinal fluid (CSF) analysis confirmed intracranial infection, leading to escalation to meropenem plus intravenous/intrathecal vancomycin, yet clinical and CSF parameters showed no improvement. Although traditional culture of pathogens and serological testing yielded negative results, M. hominis was detected in CSF by mNGS mNGS on postoperative day 19. Targeted therapy with moxifloxacin and doxycycline resulted in marked clinical improvement: fever resolved and CSF abnormalities normalized.

Conclusion: This case highlights mNGS as pivotal for diagnosing fastidious pathogens like M. hominis in culture-negative intracranial infections, enabling a critical shift from failed empirical therapy to successful pathogen-directed treatment. It further underscores the indispensable role of the clinical pharmacist in optimizing antimicrobial selection and monitoring based on mNGS findings. When empirical therapy fails and pathogen identification remains elusive in CNS infections, mNGS emerges as a valuable diagnostic option to guide targeted treatment.

Novel FKTN p. Gly424Asp variant associated with adult-onset dilated cardiomyopathy and seizures in a Chinese patient

Wen Zhang — 2026-06-07

Fukuyama congenital muscular dystrophy (FCMD) is a rare autosomal recessive α-dystroglycanopathy typically presenting in infancy with severe hypotonia, intellectual disability, and cortical malformations. Adult-onset phenotypes are uncommon and usually dominated by isolated cardiomyopathy without neurological involvement. We report the first genetically confirmed case of adult-onset FKTN-related dilated cardiomyopathy (DCM) in a Chinese patient harboring a novel homozygous FKTN missense mutation. We present here a 31-year-old man presented with acute heart failure secondary to dilated cardiomyopathy and subsequently developed a generalized tonic–clonic seizure. Neurological examination revealed mild bilateral gastrocnemius atrophy without weakness, preserved cognition, and normal deep tendon reflexes. Serum creatine kinase was markedly elevated (>7,000 U/L). Echocardiography and cardiac MRI confirmed DCM with non-compaction features. Brain MRI was unremarkable. Genetic testing identified a novel homozygous FKTN mutation (c. 1271G>A, p. Gly424Asp). Following treatment with heart failure medication and prophylactic levetiracetam, cardiac function improved, and the patient remained seizure-free during a 12-month follow-up.

Conclusions: This case expands the phenotypic spectrum of FKTN-related disorders to include adult- onset DCM accompanied by seizures. While the exact mechanism remains to be fully elucidated, the presence of seizures in the absence of cortical malformations highlights a potential functional neurological involvement. Targeted FKTN screening is recommended for adults with unexplained cardiomyopathy and markedly elevated CK.

Anti-sulfatide IgG in Miller Fisher syndrome: Report of two cases

Vishnu Prasad Rao — 2026-06-07

Anti-GQ1b IgG is the hallmark biomarker of Miller Fisher syndrome (MFS), an acute neuropathy characterized by ophthalmoplegia, ataxia and areflexia. In contrast, anti-sulfatide IgG is typically associated with chronic neuropathies, and its presence in acute presentations is uncommon. We report two female patients who presented with acute-onset giddiness, imbalance and diplopia. Initial examination showed gait ataxia, reduced reflexes and mild extraocular movement restriction, which progressed over the next few days to near complete ophthalmoplegia, consistent with classic MFS. Both patients had albuminocytologic dissociation on cerebrospinal fluid analysis. Serology showed isolated sulfatide-IgG positivity in the first case, and dual sulfatide-IgG and anti-GQ1b IgG positivity in the second. Both patients received intravenous immunoglobulin (IVIG) and showed marked clinical improvement. These cases suggest that anti-sulfatide IgG, although classically linked to chronic neuropathies, may also be detected in MFS, either alone or in combination with anti-GQ1b. Recognition of nonclassical antibodies may assist in identifying atypical or GQ1b-negative MFS- spectrum presentations and broaden the understanding of its immunological profile.

Nitrous oxide abuse-induced subacute combined degeneration: A case report highlighting vitamin B12 metabolic dysfunction and its implications

Yixin Bao — 2026-06-07

Subacute combined degeneration (SCD) of the spinal cord is typically caused by vitamin B₁₂ deficiency and represents a progressive neurological disorder. We report here a 21-year-old male admitted to the Neurology Department of the Second Affiliated Hospital of Jiaxing University with a 10-day history of progressive tetraparesis and paresthesias. Comprehensive investigations were conducted, including blood tests, cerebrospinal fluid analysis, and head magnetic resonance imaging (MRI), all of which yielded normal results. Electrophysiological studies demonstrated evidence of multifocal peripheral neuropathy. Imaging of the cervical spine revealed patchy long T2 signal abnormalities with an inverted V-sign extending from C2 to C5. Further detailed inquiry into his medical history disclosed a long- standing history of nitrous oxide inhalation. Based on these findings, the patient was diagnosed with SCD of the spinal cord induced by disrupted cobalamin metabolism associated with prolonged nitrous oxide inhalation. The patient was treated with daily intravenous injections of 1000 µg of mecobalamin and oral administration of 5 mg folic acid tablets. Following treatment, the patient exhibited some improvement in his symptoms. Early recognition, cessation of nitrous oxide exposure, and high-dose mecobalamin therapy led to partial neurological recovery.

A case report: Triangular interval syndrome in an elite swimmer – A diagnostic pitfall of painless weakness

MOHAMAD AZWAN AZIZ — 2026-06-07

Triangular interval syndrome (TIS) is a rare cause of radial nerve entrapment, typically described in throwing athletes or military personnel. We present a case of TIS in an elite swimmer, uniquely characterized by painless weakness and a normal initial neurological examination, challenging conventional diagnostic pathways. A 17-year-old male presented with a 2-month history of isolated performance decline, manifesting as a loss of power during the pull-through phase. He denied pain but reported mild posterior shoulder discomfort post-training. Notably, his initial neurological exam was normal, leading to diagnostic delay. Diagnosis was confirmed via MRI showing lateral triceps edema and subsequent EMG demonstrating partial radial nerve denervation with reinnervation. The athlete’s extreme training volume and identified glenohumeral internal rotation deficit (GIRD) were postulated as key biomechanical drivers. A multi-modal non-operative regimen including dry needling, neuromuscular electrical stimulation (NMES), and biomechanical correction resulted in complete resolution of symptoms and return to elite performance within two months. This case expands the etiological spectrum of TIS to include high-volume swimming. It underscores that TIS can present as an isolated motor syndrome without pain or initial electrodiagnostic abnormality. Clinicians should consider TIS in athletes with unexplained performance decline, utilizing advanced imaging and a high index of suspicion even in the face of normal preliminary investigations. Early, targeted intervention can yield excellent outcomes.

Reversible myotonic myopathy induced by colchicine: A rare mimic of myotonic dystrophy

Seyma Ciftci Aykac — 2026-06-07

Colchicine is widely used in the treatment of familial Mediterranean fever (FMF) and other inflammatory disorders and is generally well tolerated. However, neuromuscular toxicity may rarely occur. Although colchicine-induced myopathy has been increasingly recognized, the coexistence of clinical myotonia with electrophysiologically documented myotonic discharges remains exceptionally uncommon. We report a 45-year-old woman with FMF who developed diffuse myalgia and progressive gait disturbance over five days following an increase in colchicine dosage to 3 mg/day. Neurological examination revealed proximal muscle weakness and percussion myotonia. Laboratory studies showed elevated creatine kinase and hepatic transaminase levels, with preserved renal function. Muscle magnetic resonance imaging was normal, myositis-specific antibodies were negative, and nerve conduction studies were unremarkable. Needle electromyography demonstrated myogenic motor unit potentials with prominent myotonic discharges, predominantly in proximal lower-limb muscles. Colchicine was promptly discontinued, and intravenous hydration was initiated. Within one week, liver enzyme levels normalized, clinical myotonia resolved, and repeat electromyography showed complete disappearance of myotonic discharges, although mild myopathic features persisted. The absence of multisystem involvement, family history, and the rapid clinical and electrophysiological recovery after drug withdrawal strongly argued against a hereditary myotonic disorder and supported a diagnosis of colchicine-induced myopathy with transient myotonia. This case highlights a rare but reversible manifestation of colchicine-related neuromuscular toxicity and emphasizes the importance of considering a pharmacological etiology in patients presenting with acute or subacute proximal weakness and myotonia. Early recognition and prompt withdrawal of colchicine are essential, as clinical and electrophysiological recovery is typically complete.

A case series of false positive anti-acetylcholine receptor antibody

KO HIN KHO — 2026-06-07

Myasthenia gravis is an autoimmune neuromuscular disorder typically characterized by fluctuating weakness. Antibody-mediated immunologic attack in the postsynaptic membrane of neuromuscular junction is the key pathophysiology of the disease. Hence, anti-acetylcholine receptor (AChR) antibody test is very specific for myasthenia gravis. However, there are rare occurrences of false positive anti- acetylcholine receptor antibody. Here, we illustrated a case series of three different neurological diseases without typical courses of myasthenia gravis but having positive AChR antibody tests. Patient 1 was a 43-year-old woman presented with progressive lower limb weakness for eight months and bulbar symptom for one month and intubated for respiratory distress. She underwent intensive investigation, received steroid, plasmapheresis but not responded to treatment and required tracheostomy. She was finally diagnosed as motor neuron disease and was discharged with home ventilator. Patient 2 was a 67-year-old woman complained of progressive bilateral eye ptosis and ophthalmoplegia for 6 years without limb weakness and bulbar symptom. She did not respond to pyridostigmine. The repetitive nerve conduction study and single fiber electromyography were normal and was diagnosed as chronic progressive external ophthalmoplegia (CPEO). Patient 3 was a 50-year-old woman with recent tonsillitis presented with bulbar symptom, limbs weakness, ataxia, urinary and bowel retention. She received intravenous immunoglobulin (IVIG) and followed by plasmapheresis and steroid, responding well to treatment. Serial nerve conduction study was performed and she was eventually diagnosed as acute motor sensory axonal neuropathy, a variant of Guillain-Barré syndrome (GBS) with treatment related fluctuation. In conclusion, these cases illustrate the importance of clinical correlation with neurophysiological test. Presence of AChR antibody is not always equivalent to myasthenia gravis.

Clinical diversity of different genetic variants changes the way we look at diseases; Two cases of ACTL6B gene-related DECAM syndrome

Canan Üstün — 2026-06-07

Developmental Delay, Epileptic Encephalopathy, Cerebral Atrophy, and Abnormal Myelination syndrome (DECAM syndrome) is a rare autosomal recessive neurodevelopmental disorder with developmental delay, epileptic encephalopathy, cerebral atrophy, severe intellectual disability, and autistic features. It is also called Developmental and Epileptic Encephalopathy 76 (DEE76). In this report, we present two cases of DECAM syndrome, a 5-year-old boy and a 9-year-old girl, who presented with refractory seizures, microcephaly and severe developmental delay. Although both patients had homozygous mutation in the ACTL6B gene, the time of onset and clinical severity of the disease were different. We attributed this to the mutations being in different regions and aimed to emphasize the importance of genotype-phenotype correlation.

Fatal hyperammonemic encephalopathy triggered by valproic acid in adult-onset type II citrullinemia: A diagnostic pitfall

Young Soo Kim — 2026-06-07

Adult-onset type II citrullinemia (CTLN2) is a rare urea cycle disorder caused by SLC25A13 mutations, often misdiagnosed due to fluctuating neuropsychiatric and metabolic symptoms. Hyperammonemia is its defining feature and can be fatal if unrecognized. A 30-year-old woman with intellectual disability presented with recurrent seizure-like episodes and behavioral changes. Brain MRI showed bilateral temporal lobe abnormalities suggestive of encephalitis or metabolic encephalopathy. Despite antiviral and antiseizure therapy, her consciousness deteriorated. On the sixth hospital day, valproic acid (VPA) was administered for seizure control, after which she rapidly progressed to coma and respiratory failure. Serum ammonia levels were markedly elevated (>615 µmol/L), and metabolic studies revealed increased citrulline and arginine levels. Genetic testing confirmed compound heterozygous SLC25A13 mutations consistent with CTLN2. Despite aggressive management, the patient died 23 days after admission. This case underscores the diagnostic difficulty of CTLN2 and highlights the fatal risk of VPA-induced hyperammonemia in patients with unrecognized urea cycle disorders. Early metabolic screening should be considered in unexplained encephalopathy, especially when imaging and EEG findings are nonspecific, and VPA should be avoided to prevent catastrophic outcomes.

Association of platelet glycoprotein Ia C807T polymorphism with ischemic stroke risk in young and elderly populations in Uzbekistan: A case- control study

Adkham Yusupov — 2026-06-07

Background: Ischemic stroke remains a significant health concern, with a growing incidence among younger populations. While traditional risk factors such as hypertension and smoking are well- documented, the genetic predisposition to stroke, particularly the role of GP Ia C807T polymorphism, is still debated. Given the limited genetic studies in Central Asia, investigating this polymorphism in Uzbekistan’s young stroke patients is essential. Objective: This study aims to determine whether the GP Ia C807T polymorphism is associated with an increased risk of ischemic stroke in young individuals in Uzbekistan.

Methods: A case-control study was conducted involving 90 ischemic stroke patients aged ≤50 years, 92 patients >50 years, and 168 healthy controls. Genomic DNA was extracted from venous blood samples, and genotyping was performed using PCR-RFLP analysis. Statistical comparisons were made using logistic regression, adjusting for confounding factors.

Results: Hypertension and smoking were identified as significant risk factors for ischemic stroke in both young and elderly patients (p<0.05). However, no statistically significant association was observed between the GP Ia C807T polymorphism and ischemic stroke in either group (p>0.05).

Conclusion: This study suggests that traditional risk factors, rather than genetic variations in GP Ia C807T, play a more prominent role in ischemic stroke development among young individuals in Uzbekistan. Further research incorporating larger cohorts and additional genetic markers is needed to clarify the genetic contribution to stroke susceptibility in this population.

Impact of cumulative exposure and variations of small dense low-density lipoprotein cholesterol on the risk of incident cardiovascular diseases or stroke among middle-aged and old adults: Insights from CHARLS

Genshan Gao — 2026-06-07

Objection: This study aims to investigate the associations of cumulative small dense low-density lipoprotein cholesterol (sdLDL-C) and changes with cardiovascular disease (CVD) or stroke risk in middle-aged and old adults.

Methods: Study data were extracted from the China Health and Retirement Longitudinal Study (CHARLS) database in 2011-2015. Associations of cumulative sdLDL-C, sdLDL-C change and sdLDL-C cluster (divided into 3 classes using the k-means cluster analysis) with risk of CVD or stroke were investigated utilizing multivariate logistic regression analysis, which evaluated through odds ratio (OR) with 95% confidence interval (CI).

Results: Follow-up until 2020, 662 of 4,353 participants had CVD or stroke. After adjusting for selected covariates, compared to lower cumulative levels of sdLDL-C (≤82.2), cumulative sdLDL-C levels of (99.4, 120] (OR=1.44, 95%CI: 1.12-1.86) and >120 (OR=1.41, 95%CI: 1.09-1.82) were associated with increased CVD/stroke odds, respectively. Compared to persistent low sdLDL-C change levels, persistent middle, persistent high and increasing sdLDL-C change were all linked to increased odds of CVD/stroke (all P<0.05). Participants with sdLDL-C level of Class 2 and Class 3 had increased odds of CVD/stroke risk, compared to those with sdLDL-C level of Class 1 (all P<0.05). Similar associations were observed between sdLDL-C and CVD risk but not with stroke.

Conclusions: High cumulative sdLDL-C levels and stably high sdLDL-C change was associated with an increased CVD/stroke risk. Timely monitoring sdLDL-C change may play a pivotal role in mitigating disease incidence, and however, targeted interventions and the underlying mechanisms of these associations need further clarification.

Predictive value of plasma sLRP1 for three-month clinical outcome in acute ischemic stroke and its potential pathophysiological mechanisms: A retrospective and observational study

Tingting Li — 2026-06-07

Background & Objective: Acute ischemic stroke (AIS) remains a leading global cause of mortality and disability; thus, accurate early prognosis is critical for guiding personalized management. Soluble low-density lipoprotein receptor-related protein 1 (sLRP1), a circulating protein implicated in neuroinflammatory regulation, has emerged as a potential biomarker in neurodegenerative and vascular pathologies. However, its prognostic significance in AIS remains undefined. This study investigated the prognostic value of admission plasma sLRP1, nuclear factor kappa B p65 subunit (NF- κB p65), and interleukin-6 (IL-6) levels regarding 90-day functional outcomes in AIS patients, while exploring potential underlying pathophysiological interrelationships.

Methods: In this retrospective observational study, we recruited patients with first-ever AIS. Plasma sLRP1, NF-κB p65, and IL-6 levels were quantified from samples obtained at admission. The primary endpoint was poor functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score of 3–6. Prognostic capabilities were assessed using univariate and multivariate logistic regression models and receiver operating characteristic (ROC) curve analyses. Correlations among the biomarkers were also evaluated.

Results: A total of 155 AIS patients were included (median age 68.00 [IQR 60.00–75.00]; 61.29% male). Admission levels of sLRP1, NF-κB p65, and IL-6 were significantly elevated in patients with poor outcomes (all P < 0.01). Multivariate regression identified all three markers as independent predictors of 90-day poor functional outcomes. ROC analysis yielded an area under the curve (AUC) of 0.771 for sLRP1 alone, which improved to 0.839 when combined with NF-κB p65 and IL-6. Furthermore, sLRP1 levels were positively correlated with NF-κB p65 (R = 0.331, P < 0.001) and IL-6 (R = 0.388, P < 0.001), suggesting that sLRP1 may contribute to AIS pathophysiology by mediating cytokine release via the NF-κB inflammatory pathway.

Conclusion: Plasma sLRP1 represents a novel prognostic biomarker for AIS, offering potential advantages over conventional inflammatory markers. The identification of the sLRP1-NF-κB-IL-6 axis highlights a critical neuroinflammatory pathway, positioning sLRP1 as both a predictive tool and a potential therapeutic target. Integrating this biomarker panel into clinical practice could enhance early risk stratification, guide targeted anti-inflammatory interventions, and improve prognostic management in AIS.

Associations between hematological inflammatory markers, infarct volume, and stroke severity in patients with obstructive sleep apnea and anterior circulation non-large artery occlusion

Li Zhang — 2026-06-07

Background: Neuroinflammatory processes are recognized as critical contributors to the pathophysiology of acute ischemic stroke (AIS). Hematological inflammatory markers have demonstrated a strong association with the progression and clinical prognosis of AIS.

Methods: A retrospective review was conducted on the clinical records of patients with AIS involving the anterior circulation without evidence of large artery occlusion (LAO) who received treatment at a single institution between January 2019 and September 2021. Participants were stratified according to the presence or absence of obstructive sleep apnea (OSA) prior to stroke onset. Multiple linear regression models were applied to evaluate the relationships among hematological inflammatory markers, vascular risk factors, infarct volume, and stroke severity.

Results: Infarct volume demonstrated a significantly positive association with both the systemic immune-inflammation index (SII) (p = 0.002) and mean platelet volume (MPV) (p = 0.03). Stroke severity at the time of hospital admission demonstrated a significant negative association with pre-stroke OSA history (p = 0.026) and the monocyte-to-lymphocyte ratio (MLR) (p = 0.002), and a significant positive association with neutrophil count (p < 0.001) and platelet distribution width (PDW) (p = 0.048). No statistically significant relationship was identified between the SII and stroke severity, or between a history of pre-stroke OSA and infarct volume.

Conclusion: Elevated levels of SII and MPV may be independently associated with increased infarct volume in patients with AIS. However, our findings did not reveal an association between pre-stroke OSA with increased infarct volume or greater stroke severity at presentation.

The effect of carotid artery geometric measurements and degree of stenosis on infarct volume and in- hospital mortality in patients with middle cerebral artery infarction

Muzaffer Güneş — 2026-06-07

Background & Objective: Atherosclerosis of the internal carotid artery (ICA) is a major cause of middle cerebral artery (MCA) infarction. This study aimed to investigate the relationship between carotid artery angles and diameters and infarct volume, and to determine the impact of these measurements on in-hospital mortality in patients with MCA infarction.

Methods: This retrospective observational cohort study included patients with symptomatic ICA stenosis of 50–95% and no other identifiable etiology who had suffered an MCA infarction. From computed tomography angiography images, we measured the common carotid artery (CCA)–ICA angle, the carotid bifurcation angle, and the diameters of the carotid arteries. Infarct volumes were obtained from diffusion-weighted MRI. Statistical analyses included the independent two-sample t-test, Mann–Whitney U test, Spearman’s rho correlation, logistic regression, and receiver operating characteristic (ROC) analysis.

Results: A total of 79 patients (46 survivors, 33 non-survivors) were analyzed. Non-survivors had significantly larger infarct volumes (p<0.001). They also exhibited narrower CCA–ICA angles (p=0.001) and wider bifurcation angles (p<0.001). Infarct volume showed a weak but significant correlation with both bifurcation angle (r=0.327, p=0.003) and degree of ICA stenosis (r=0.371, p=0.001). Each 1° increase in bifurcation angle was associated with a 1.433-fold rise in mortality risk (p=0.013). The bifurcation angle had a strong predictive value for mortality (AUC=0.896).

Conclusions: In patients with MCA infarction, a wider carotid bifurcation angle and a narrower CCA– ICA angle are associated with in-hospital mortality. A 1° increase in the bifurcation angle increases the risk of in-hospital mortality by 1.433 times.

Ticagrelor plus aspirin vs clopidogrel plus aspirin in mild non-cardioembolic ischemic stroke: A randomized, controlled, active comparator arm, outcome assessor blind, feasibility study

Nasim Tabrizi — 2026-06-07

Background: The risk of recurrence after a transient ischemic attack (TIA) or minor stroke is high especially within three months after the first event. The aim of the present study was to assess the efficacy of ticagrelor plus aspirin in reduction of mild non-cardioembolic ischemic stroke or high- risk TIA recurrence during the first 3 months.

Methods: This was a randomized, controlled, active comparator arm, outcome assessor blind, parallel group, study designed on 90 patients with diagnosis of non-cardioembolic mild ischemic stroke or high-risk TIA admitted in Bu-Ali Sina Hospital, Sari, Iran. After meeting all inclusion and exclusion criteria, patients were randomly assigned to ticagrelor 90 mg BID plus aspirin (ASA) 80 mg daily or clopidogrel 75 mg daily plus ASA 80 mg daily (1:1 ratio) until 21 days and then ASA 80 mg daily. Participants were visited at month one and three. Any adverse events, serious side effects and outcome events were recorded. The primary outcome was defined as ischemic stroke recurrence.

Results: Ninety-four patients were recruited into this study (47 in ticagrelor and 47 in clopidogrel group). Stroke recurred in 2 patients in the clopidogrel group and no recurrence noted in the ticagrelor group (OR: 0.18; 95% CI = 0.008–3.932, P=0.27). No major hemorrhagic event occurred in either group.

Conclusion: Ticagrelor plus aspirin and clopidogrel plus aspirin showed similar efficacy and safety in preventing recurrence of mild non-cardioembolic stroke and high-risk TIA. However, uncertainties remain due to the small sample size, and larger trials are needed.

Clinical efficacy and safety evaluation of intravenous thrombolysis combined with carotid artery stenting in the treatment of acute cerebral infarction

Lei Lei — 2026-06-07

Objective: To evaluate the clinical efficacy and safety of intravenous thrombolysis (IVrtPA) combined with carotid artery stenting (CAS) in the treatment of acute cerebral infarction (ACI).

Methods: We conducted a single-center retrospective cohort of consecutive adults with anterior-circulation large- vessel occlusion (LVO) and ipsilateral carotid disease between March 2021 and March 2023. Patients receiving intravenous thrombolysis (IVT; alteplase 0.9 mg/kg; 10% bolus then 60-min infusion) plus mechanical thrombectomy (MT) were classified as the control group; those additionally undergoing carotid artery stenting (CAS) for flow-limiting extracranial internal carotid artery (ICA) lesions comprised the intervention group. The primary outcome was good functional outcome (modified Rankin Scale [mRS] 0–2) at 90 days. Safety outcomes were intracranial hemorrhage (ICrH) within 24 h and cumulative ICrH through 7 days. Secondary outcomes included 30-day reinfarction, 90-day all-cause mortality, and 12-month stent patency (duplex/CTA).

Result: Among 120 patients (intervention n=40; control n=80), the 90-day mRS 0–2 rate was 70% (28/40) vs 50% (40/80) (P=0.037). Day-7 NIHSS improvement was larger with IVT+MT+CAS (8.03 ± 1.15 vs 5.39 ± 2.07; P<0.001). ICrH at 24 h (10.0% vs 7.5%) and cumulative ICrH through 7 days (10.0% vs 7.5%) did not differ significantly. Thirty-day reinfarction and 90-day mortality showed no statistically significant differences. Twelve month stent patency was 90% (36/40).

Conclusion: In LVO with significant carotid disease, adding CAS to IVT+MT was associated with improved early neurological recovery and high 12-month stent patency without an excess of early ICrH; confirmation in larger, multicenter cohorts is warranted.

Risks for early neurological deterioration after thrombolytic therapy in patients with acute ischemic stroke

Zhilan Zhang — 2026-06-07

Background: Early neurological deterioration (END) is a common complication following intravenous thrombolysis in acute ischemic stroke (AIS). This study aimed to identify factors associated with END to improve early risk stratification and management.

Methods: We conducted a prospective observational study including AIS patients treated with intravenous recombinant tissue plasminogen activator (rt-PA) within 4.5 hours of symptom onset. END was defined as an increase of ≥ 4 points in the NIHSS score within 24 hours after thrombolysis. Baseline data included demographics, vascular risk factors, prior medication use, NIHSS score, onset-to-needle and onset-to-thrombectomy times, laboratory markers (including inflammatory cytokines and platelet function), and neuroimaging findings. Univariate and multivariate logistic regression analyses were performed, and model performance was evaluated using receiver operating characteristic (ROC) curves.

Results: Among 300 enrolled patients, 66 (22.0%) developed END. Multivariate analysis identified higher NIHSS score at admission (P=0.011), longer onset-to-needle time (P=0.007), proximal large vessel occlusion (P=0.010), diabetes (P=0.018), elevated interleukin-6 (IL-6) levels (P<0.001), and increased maximum aggregation rate induced by arachidonic acid (MAR_AA) (P<0.001) as independent predictors of END. A predictive model incorporating these factors demonstrated excellent discriminative ability (AUC=0.873; 95% CI: 0.844–0.902).

Conclusion: Neurological severity, treatment delay, metabolic vulnerability, inflammation, and platelet hyperreactivity collectively contribute to END after thrombolysis. Identifying high-risk patients through clinical and biomarker profiling may help improve outcomes through early intervention.

Interaction analysis of CONUT score and NLR in predicting functional outcomes after mechanical thrombectomy

Xin Nie — 2026-06-07

Background: This study investigates the prognostic value of the Controlling Nutritional Status (CONUT) score and its relationship with systemic inflammation, measured by the Neutrophil-to- Lymphocyte Ratio (NLR), in patients with acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). Specifically, we aimed to determine whether NLR acts as a mediator or an effect modifier in the relationship between malnutrition and poor outcomes.

Methods: This retrospective cohort study analyzed 470 AIS patients undergoing MT. Malnutrition was assessed by the CONUT score, and inflammation was evaluated by NLR upon admission. These assessments were used to investigate their association with the primary outcome, which was poor functional status defined as modified Rankin Scale scores 3 to 6 at 90 days. Multivariable logistic regression, interaction analysis, and exploratory mediation analysis were performed to explore the relationships between malnutrition, inflammation, and functional outcomes.

Results: Of 470 patients, 57.2% had poor outcomes. The CONUT score was identified as a robust independent predictor of poor prognosis (OR = 1.66, 95% CI: 1.43–1.93, P < 0.001). Mediation analysis revealed that NLR did not significantly mediate the effect of the CONUT score on patient outcomes (P > 0.05). However, a significant synergistic interaction was observed between the CONUT score and NLR (P for interaction = 0.034). Specifically, the risk of poor outcome associated with higher CONUT scores was markedly greater in patients with high inflammatory levels compared to those with low inflammatory levels. Adding CONUT significantly improved the predictive accuracy of the baseline model, with the AUC increasing from 0.785 to 0.842 (P < 0.001).

Conclusions: Malnutrition (high CONUT score) is a strong predictor of poor outcomes after MT. Importantly, systemic inflammation modifies rather than mediates this risk, meaning that it influences the severity of risk without being the direct cause, which supports a synergistic double-hit effect in which malnutrition and inflammation jointly exacerbate patient outcomes. Joint assessment of immuno- nutritional status helps identify high-risk patients who may benefit from intensive management.

Hospital Frailty Risk Score (HFRS) in ischemic stroke

Sher Yin Tan — 2026-06-07

Background & Objective: Frailty results from an age-associated decline in physiological reserve and function and is prevalent in older adults. In this retrospective cohort study, we aimed to validate the Hospital Frailty Risk Score (HFRS) in predicting adverse events and hospitalisation utilisation in older patients hospitalised with ischemic stroke and hypothesise that frailty is a comparable predictor of adverse outcomes in stroke.

Methods: Older patients aged 65 years and above with ischemic stroke admitted to a tertiary hospital in Singapore from 1st January 2019 to 31st December 2019 were identified and categorised into high risk (>15), intermediate risk (5-15) and low risk (<5) of frailty using HFRS.

Results: A total of 1,023 patients with ischemic stroke were included in this study. HFRS was categorised as high risk in 271 patients (26.5%), intermediate risk in 544 patients (53.2%) and low risk in 208 patients (20.3%). Patients with higher HFRS scores were older, more likely female, have lower BMI and more comorbidities. Higher HFRS scores was also associated with increased length of stay, 90 day and 1 year mortality, but not 30-day readmission and inpatient mortality. Predictive models which incorporated HFRS and other relevant variables showed good predictive value for long length of stay and 1 year mortality with AUC of 0.811 (0.744 – 0.878) and 0.749 (0.619 – 0.878) respectively.

Conclusion: Our study has shown that patients with high risk of frailty have higher healthcare utilisation than low risk patients. Identification of frailty can help stratify care for older frail patients.

Impact of laboratory-based frailty assessment on clinical outcomes following endovascular thrombectomy in elderly patients with acute ischemic stroke

Hongli Liao — 2026-06-07

Objective: To investigate the prognostic value of frailty assessed by laboratory-based frailty index (FI-Lab) in elderly patients with acute ischemic stroke (AIS) undergoing endovascular thrombectomy (EVT).

Methods: We conducted a single-center retrospective cohort study of elderly AIS patients who underwent EVT between January 2018 and April 2024. FI-Lab was constructed using a deficit accumulation model incorporating 44 laboratory parameters. Patients were categorized as robust (<0.20), pre-frail (0.20-0.35), or frail (≥0.35) based on established cutpoints. The primary endpoint was 90-day mortality; secondary endpoints included 90-day poor functional outcome and in-hospital mortality. We used multivariable logistic regression to examine associations between frailty and outcomes, restricted cubic spline analysis to assess dose-response relationships.

Results: The study included 335 patients: 107 robust (31.9%), 170 pre-frail (50.7%), and 58 frail (17.3%). Ninety-day mortality increased with frailty severity: 12.1% (robust), 24.1% (pre-frail), and 34.5% (frail) (P=0.003). In fully adjusted models, pre-frail patients had 2.33-fold higher 90-day mortality risk compared with robust patients (95% CI: 1.07-5.37, P=0.038), while frail patients had 5.70-fold higher risk (95% CI: 2.22-15.46, P<0.001). Similarly, frail patients showed increased risks of poor functional outcome (adjusted odds ratio [OR]=4.05, 95% CI: 1.68-10.33, P=0.002) and in-hospital mortality (adjusted OR=6.34, 95% CI: 2.16-20.40, P=0.001). Each 0.1-unit increase in FI-Lab as a continuous variable was associated with 99%, 67%, and 105% higher risks of 90-day mortality, poor functional outcome, and in-hospital mortality, respectively (all P<0.05). Restricted cubic spline analysis confirmed significant linear dose-response relationships between FI-Lab and all adverse outcomes (all P-nonlinear >0.05). No significant interactions were observed across subgroups (all P for interaction >0.05).

Conclusion: Laboratory-based frailty assessment independently predicts adverse outcomes following EVT in elderly AIS patients. FI-Lab provides an objective, standardized tool for risk stratification and clinical decision-making in this population.

Peripheral BDNF gene expression before and after rehabilitation in ischemic stroke: A preliminary study

Nurhaziqah binti Ramlan — 2026-06-07

Background: Ischemic stroke is a leading global cause of disability, accounting for approximately 87% of all stroke cases. Rehabilitation strategies that promote neuroplasticity show promise in improving recovery outcomes, with increased expression of the brain-derived neurotrophic factor (BDNF) gene playing a key role in neuronal survival and synaptic plasticity. However, the effects of rehabilitation therapy on BDNF gene expression in ischemic stroke patients are rarely reported. This study aims to compare BDNF gene expression levels in ischemic stroke patients before and after rehabilitation.

Methods: In brief, total RNA was extracted from ischemic stroke patients before (n = 43) and after (n = 22) rehabilitation and converted into cDNA. Out of the 22 post-rehabilitation ischemic stroke patients, only 16 were paired. BDNF gene expression levels of pre- and post-rehabilitation were measured using a quantitative real-time polymerase chain reaction. A Mann-Whitney U test was applied to compare overall BDNF expression levels in ischemic stroke patients, while a Wilcoxon Signed-Rank test was used to assess changes in BDNF expression in the 16 paired ischemic stroke patients who completed the rehabilitation therapy.

Results: The results revealed a significant 3.81-fold increase in overall BDNF gene expression in post-rehabilitation ischemic stroke patients (p-value = 0.048), as determined by the Mann-Whitney U test. Notably, the Wilcoxon Signed-Rank test showed a highly significant 7.78-fold increase in BDNF expression in the 16 paired patients post-rehabilitation compared to pre- rehabilitation (p-value = 0.004).

Conclusions: The results support the potential of BDNF gene as a molecular marker of rehabilitation- induced neuroplasticity. These findings warrant further validation in larger studies integrating both molecular and clinical outcome measures.

Stroke patients in an alcohol withdrawal state: A cross- sectional analysis of clinical profiles and functional outcomes in a tertiary hospital in the Philippines

Jenielyn Nazaire — 2026-06-07

Background & Objective: Acute stroke patients are at risk for a wide range of complications. When these complications overlap with acute Alcohol Withdrawal Syndrome (AWS), they can lead to adverse events such as death, disability, or delayed recovery. However, evidence regarding this overlap, particularly in Asian populations, is scarce. This study aims to characterize the clinicodemographic features and outcomes of Filipino stroke patients with AWS and investigate the relationship between AWS severity and functional recovery.

Methods: We conducted a retrospective, cross-sectional study of adult stroke patients with AWS admitted to the Department of Neurology at a tertiary hospital from 2018 to 2023. Demographic data, clinical features, complications, and outcomes were collected. Associations between AWS severity (Clinical Institute Withdrawal Assessment of Alcohol Scale–Revised [CIWA- Ar]), stroke severity (National Institutes of Health Stroke Scale [NIHSS]), and functional outcomes (modified Rankin Scale [mRS]) were analyzed using Spearman’s rho correlation and Fisher’s exact test.

Results: During the study period, 36 patients met the inclusion criteria. There was a strong male predominance (94.4%), with the majority aged 40–59 years (77.8%). Hemorrhagic stroke was the most common subtype (83.3%). Upon admission, 47.2% presented with mild AWS, and 55.6% manifested withdrawal symptoms within 24 hours to one week of admission. The mortality rate was 22.2% (95% CI: 10.1–39.2%), while 25.0% (95% CI: 12.1–42.2%) of patients were discharged with no significant disability (mRS 0–2). A significant positive correlation was found between AWS severity (CIWA-Ar scores) and functional disability (mRS) (ρ = 0.360, p = 0.031). Baseline demographic factors did not show a statistically significant association with functional outcomes.

Conclusion: Increasing severity of alcohol withdrawal is significantly associated with poorer functional outcomes in acute stroke patients. These findings emphasize the need for early risk stratification using the CIWA-Ar scale and the implementation of multidisciplinary management protocols to optimize recovery in this vulnerable population.

Glucose-to-potassium ratio as a predictor of in-hospital mortality in patients with spontaneous intracranial hemorrhage

Abdullah Algın — 2026-06-07

Background & Objective: Spontaneous intracranial hemorrhage (ICH) is associated with high morbidity and mortality. Early identification of patients at risk for poor outcomes is crucial to guide management and optimize intensive care utilization. Glucose-to-potassium ratio (GPR) is an emerging biomarker that may reflect combined metabolic and systemic derangements. The objective of this study is to evaluate the prognostic performance of GPR in predicting in-hospital mortality among patients with spontaneous ICH.

Methods: In this retrospective observational study, 168 consecutive patients diagnosed with spontaneous ICH between January and December 2024 were included. Demographics, clinical parameters, laboratory results, and interventions were extracted from electronic medical records. The primary outcome was in-hospital mortality. GPR was calculated from admission serum glucose and potassium levels. Statistical analyses included Mann-Whitney U and chi-square tests for group comparisons, receiver operating characteristic (ROC) curve analysis for predictive performance, and multivariable logistic regression to identify independent mortality predictors.

Results: Among 168 patients, 103 (61.3%) survived and 65 (38.7%) died during hospitalization. Non-survivors were older (median 64 vs. 58 years, p = 0.017) and had lower GCS scores (12 vs. 15, p < 0.001). ROC analysis of GPR yielded an area under the curve of 0.718 (95% CI, 0.637–0.800) with an optimal cut-off of ≥37.29, sensitivity of 65.6%, and specificity of 70.8%. In multivariable logistic regression, higher GPR (OR 1.04, 95% CI 1.01–1.07, p = 0.004), older age (OR 1.04, 95% CI 1.01–1.06, p = 0.002), and decompressive craniectomy (OR 3.60, 95% CI 1.52–8.53, p = 0.004) independently predicted in- hospital mortality.

Conclusion: GPR is a simple, cost-effective, and readily obtainable biomarker that independently predicts in-hospital mortality in patients with spontaneous ICH. When combined with established predictors such as age and surgical intervention, GPR may facilitate early risk stratification and guide clinical management. Prospective multicenter studies are warranted to further validate these findings.

The beneficial effects of the herbal medicine di-huang-yin-zi (DHYZ) on patients with moderate volume of basal ganglia hemorrhage: A randomized, double- blind, placebo-controlled study

Mei Yu — 2026-06-07

Objective: In China, Di-Huang-Yin-Zi (DHYZ) 地黄饮子, a traditional polyherbal formula with rehmannia as its key ingredient, has been applied in treating neurological disorders since the Song dynasty, around 900 years ago. This study aimed to explore the safety and efficacy of DHYZ in treating patients with moderate basal ganglia hemorrhage.

Method: This double-blind, placebo-controlled trial randomly assigned patients with moderate basal ganglia hemorrhage to receive either DHYZ (n = 40) or placebo (n = 40) for 8 weeks. Both groups concurrently underwent rehabilitation therapy. Fugl-Meyer assessment (FMA), activities of daily living (ADL), functional walking scale (FAC), and Modified Rankin Scale (MRS) were evaluated at the 4th, 6th, and 8th weeks of treatment.

Results: At the study’s conclusion, the DHYZ group demonstrated significantly higher scores on the FMA, ADL, FAC, and MRS compared to the placebo group (all P<0.05). Additionally, no drug-related serious adverse events were recorded.

Conclusion: DHYZ enhanced neurological function in patients with moderate basal ganglia hemorrhage and could serve as an effective adjunctive treatment to promote functional recovery.

The effect of epilepsy education on seizure intervention, knowledge, and stigma levels among high school students: A randomized controlled study

Kubra Yeni — 2026-06-07

Background & Objective: Misinformation and misconceptions regarding epilepsy in society contribute to the increasing stigma surrounding the condition and its patients. This study aimed to examine the impact of education provided to high school students about epilepsy on their awareness of seizure intervention, knowledge level, and stigma associated with the condition.

Method: This study, designed as a randomized controlled experimental study with pre-test and post-test measurements, collected data between February and May 2024. To gather data, the Student Information Form, the Epilepsy Knowledge Scale, the Epilepsy Stigma Scale, and the Numerical Rating Scale were utilized. A total of 256 high school students participated in the experimental group, while 201 students were included in the control group.

Results: The mean total score on the Epilepsy Knowledge Scale in the experimental group increased, indicating a significant improvement compared to the control group (p<0.001, Cohens d=1.57, effect size 0.61). A significant decrease was found in all sub-dimensions and total scores of the Epilepsy Stigma Scale in the experimental group. (p<0.001, Cohens d= -0.92, effect size -0.41). Both groups’ level of competence in seizure intervention was similar before the training (p=0.531); however, a significant increase was noted in the experimental group post-education (p=0.002, Cohens d= 1.74, effect size 0.65).

Conclusion: Education given to high school students about epilepsy increases their knowledge and seizure intervention competence and reduces the level of stigma. In light of these findings, it is recommended that educational initiatives aimed at reducing stigma against individuals with epilepsy be widely implemented across the community.

Effect of magnesium sulfate administration on the survival of adult and pediatric non-neonatal tetanus patients in a tertiary hospital in the Philippines: A retrospective cohort study

Mario Jr Prado — 2026-06-07

Background & Objective: Locally, there are no recommendations on the use of magnesium sulfate (MgSO4) among tetanus patients. Moreover, some neurologists are unaware of its benefits in this cohort. Most start MgSO4 only when the patients are in the severe stage, have signs of dysautonomia, or if the physician is confident in its administration. This paper will determine the effect of MgSO4 on the survival of adult and pediatric non-neonatal tetanus patients in a tertiary hospital in the Philippines.

Methods: This study utilized a retrospective cohort study design. Data from a previous study by Lanuza et al. (2024) was utilized. Baseline comparisons of MgSO4 versus non-MgSO4 groups were done using Wilcoxon rank sum test or independent t-test for continuous data while a Fisher Exact test was used for comparison of proportions. Those with a p-value lower than 0.2 were used for Cox regression analysis.

Results: Crudely, survival is better in the MgSO4 group, and although this became non-significant when confounders were accounted, the survival in the MgSO4 group was still markedly higher than non-MgSO4 group. In terms of age group, MgSO4 was beneficial in both pediatric and adult patients, but only significant on the latter. The survival of MgSO4 administered non-neonatal tetanus patients was significantly higher among severe tetanus patients and among those without dysautonomia.

Conclusion: Administration of MgSO4 in non-neonatal tetanus patients, may be effective in improving survival. Moreover, its benefit is magnified among adult patients, with severe tetanus and those with no dysautonomia.

Comparative diagnostic yield of median and ulnar nerve repetitive nerve stimulation in generalized myasthenia gravis

Betul Ozenc — 2026-06-07

Background & Objective: Ulnar nerve repetitive nerve stimulation (RNS) is widely used in the electrophysiological evaluation of myasthenia gravis (MG), but its limited diagnostic sensitivity remains a challenge. This study aimed to directly compare the diagnostic sensitivity of low-frequency (3 Hz) median and ulnar nerve RNS in generalized MG patients positive for acetylcholine receptor (AChR) or muscle-specific kinase (MuSK) antibodies.

Methods: In this retrospective single-center study, 35 patients diagnosed with generalized MG and seropositive for AChR or MuSK antibodies were evaluated. All underwent both median and ulnar nerve RNS testing. Electrophysiological recordings were obtained from the abductor pollicis brevis (APB) muscle for the median nerve and the abductor digiti minimi (ADM) muscle for the ulnar nerve.

Results: Abnormal decremental responses were more frequent in median nerve RNS than in ulnar nerve RNS, especially among newly diagnosed patients and those with higher AChR antibody levels, although this difference was not statistically significant. Importantly, the mean decrement magnitude was significantly greater in the median nerve compared to the ulnar nerve (17.1% vs. 9.4%; p = 0.018). This difference was particularly notable in patients with mild MG symptoms (MGFA class II and III).

Conclusion: Median nerve RNS showed higher sensitivity and greater decrement magnitude than ulnar nerve RNS, particularly in mild generalized MG cases. These findings suggest that median nerve RNS is a valuable complementary diagnostic tool in MG, especially during early disease stages.

Red blood cell distribution width/Albumin ratio as an independent predictor of diabetic peripheral neuropathy: A retrospective study

Gulhan Sarıcam — 2026-06-07

Background & Objective: Diabetic peripheral neuropathy (DPN) is a common chronic complication of diabetes characterized by the involvement of the peripheral nervous system. This study aimed to investigate the association between the red blood cell distribution width/albumin ratio (RAR) and the presence of diabetic peripheral neuropathy (DPN).

Methods: The association between DPN, RAR, and other variables was examined using logistic regression analysis. To determine the predictive validity and optimal cutoff value of RAR for the presence of DPN, Receiver Operating Characteristic (ROC) curve analysis was performed to calculate the Area Under the Curve (AUC).

Results: Compared to those without DPN, patients with DPN had a significantly higher prevalence of hypertension (p=0.006), a higher rate of smoking (p=0.002), and a longer duration of diabetes (p<0.001). Patients with DPN had significantly lower albumin levels (p<0.001), and significantly higher RDW (p<0.001) and RAR (p<0.001) values. As an independent variable, RAR was independently associated with higher odds of DPN (OR: 1.545, 95% CI: 1.235–1.914, p<0.001). The optimal cutoff value for RAR to predict the presence of DPN was determined to be 4.4 %/(g/dL) (Spec.: 99.2%, Sen.: 32.2%, AUC: 0.67).

Conclusion: Our findings suggest that RAR is an independent predictor of DPN and may serve as a complementary biomarker compared with RDW or albumin levels alone. Further prospective, multi- center studies with larger sample sizes are needed to more robustly establish the association between RAR and DPN.

Distinctive features and outcome-associated factors in generalized myasthenia gravis: A comparison of bulbar- and extremity-predominant subtypes

Yagmur Inalkac Gemici — 2026-06-07

Background: Risk factors for the conversion of ocular-onset myasthenia gravis (MG) to generalized MG (GMG) have been studied, but the characteristics of initially generalized onset MG subtypes remain unclear. This study aimed to identify distinguishing features of GMG by classifying patients into bulbar-predominant (GMG-B) and extremity-predominant (GMG-A) subgroups, and to evaluate prognostic factors associated with poor treatment response.

Methods: A retrospective analysis was conducted on patients between January 2009 and January 2024 who met predefined inclusion and exclusion criteria. Demographic, clinical, electrophysiological, laboratory, and treatment data were collected. Statistical analyses were performed to identify features of GMG subtype and markers of poor treatment response.

Results: A total of 118 patients were included (58 GMG-A, 60 GMG-B). GMG-B was associated with older age at onset, late-onset MG (>50 years), and male gender, whereas GMG-A was more common in early-onset MG (<50 years), female patients, and those with thymic pathology. MuSK antibody positivity strongly predicted poor treatment response, while AChR antibody positivity was associated with favorable outcomes.

Conclusion: This study is the first to examine distinctive features of GMG subtypes without preceding ocular symptoms and prognostic factors. Demographic variables (age at onset, onset category, and gender) and thymic pathology were significant predictors of GMG subtypes. Among laboratory markers, MuSK antibody positivity was the only independent predictor of poor treatment response.

Early use of rituximab in myasthenia gravis in a resource-limited setting: A retrospective cohort study from a tertiary center in Pakistan

Zainab Memon — 2026-06-07

Background: Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction, most commonly mediated by acetylcholine receptor antibodies. Standard treatments include corticosteroids, acetylcholinesterase inhibitors, and conventional immunosuppressants, while intravenous immunoglobulin (IVIg) or plasma exchange is reserved for refractory disease or myasthenic crises. Rituximab, a CD20-targeting monoclonal antibody, has demonstrated efficacy in treatment-resistant MG, particularly in MuSK-positive cases. However, its use early in the disease course, particularly soon after diagnosis or after failure of only one immunosuppressant remains underexplored, especially in resource-limited settings where access to IVIg and recurrent hospitalizations is often constrained. In our cohort, rituximab was initiated at a median disease duration of one year, although seven patients had experienced a prior myasthenic crisis. This study evaluates the efficacy and safety of early rituximab use in such settings.

Methods: In this retrospective cohort study (Dec 2021–June 2024), 12 patients with generalized MG were treated with rituximab and followed for 18 months. Clinical outcomes, including MGFA-Post Intervention Status, corticosteroid dose reduction, and adverse effects, were assessed.

Results: Seven patients had a history of myasthenic crisis before rituximab; only one had a recurrence after treatment. Overall, 91.7% of patients showed significant clinical improvement and/or reduced need for symptomatic and immunosuppressive therapy. At 18 months, Myasthenia Gravis Foundation of America (MGFA) post- intervention status indicated complete stable remission in 11%, pharmacologic remission in 11% while the rest had minimal manifestations only. Mean corticosteroid doses dropped by 22.5 mg after the first rituximab cycle, 26.4 mg after the second and 29.8 mg after the third. Seventy-five percent experienced no major treatment-related complications.

Conclusion: Early rituximab use in generalized MG appears effective and steroid-sparing, with potential to lessen disease burden and healthcare costs in resource-constrained settings.

Deletions in OPTN gene and literature review

Mehmet Burak Mutlu — 2026-06-07

Amyotrophic lateral sclerosis 12 with or without frontotemporal dementia (ALS12) is a subtype of ALS that is a neurodegenerative disorder onset in adulthood and is characterized by slowly progressive. The ALS12 is caused by a heterozygous or homozygous mutation in the Optineurin gene (OPTN) on chromosome 10p13. In this study, whole genome sequencing (WGS), utilizing next-generation sequencing techniques was performed to identify genes associated with ALS in the patient. These technologies utilize high-throughput DNA sequencing of the whole genome, representing a highly effective approach to the assessment of neurodegenerative disorders. Optical Genomic Mapping (OGM) is a new cytogenomics technics has taken the technology to the next level in the cytogenetics field by enabling the mapping of all types of structural variants (SVs) at high resolution in a single assay. It has become a prominent diagnosis method in neurogenetics and other disciplines in recent years with its ability to analyze variants that other technologies cannot detect by reaching high-resolution values that other technologies cannot reach, by using long read and specific labeling methods. In this study, we found the novel homozygous OPTN gene deletion by OGM in a patient with diagnosed ALS12 and confirmed and detected precise deletion breakpoints by WGS. We aimed to explore the utility of OGM and WGS as a method of characterizing the SVs associated with the Alu-mediated rearrangement.

The relationship between Helicobacter infection and endoscopic upper gastrointestinal diseases and migraine

sükrü erdoğan — 2026-06-07

Objectives: Migraine is often associated with various gastrointestinal (GI) symptoms and disorders, including Helicobacter pylori (Hp) infection. The aim of this study was to investigate both the relationship between migraine and Hp infection and the relationship between migraine and endoscopic upper GI diseases.

Methods: This prospective observational case-control study involved 91 migraine patients and 80 control individuals with no history of migraines presenting with upper GI symptoms. Both groups underwent upper GI endoscopy, and gastric biopsy specimens were histopathologically examined. Headache frequency, duration and pain intensity (measured by VAS) were re-evaluated in the Hp-positive migraine group at week 8 post-eradication.

Results: There was no statistically significant difference between migraine and control groups regarding Hp prevalence (p=0.117). Gastroesophageal reflux disease (GERD) was the most prevalent endoscopic upper GI condition in migraine patients (52.7%) than control group. It was statistically significant (p < 0.001). There was no statistically significant association detected between GERD and Hp in migraine subgroups (p =0.966), indicating independence of GERD from Hp. 40.7% of migraine patients had moderate chronic inflammation in the gastric antrum, while this rate was 25.0% in the control group (p=0.037). 30.8% of migraine patients had moderate acute inflammation in the gastric antrum, while this rate was 28.7% in the control group (p=0.036). While moderate acute inflammation was 45.3% in Hp-positive migraine patıents, it was 10.5% in Hp-negative migraineurs( p <0.001). While severe chronic inflammation was present in 7.5% of Hp-positive migraine patients, it was absent in Hp-negative migraineurs. Moderate chronic inflammation was observed in 52.8% of Hp-positive and 23.7% of Hp-negative migraine patients, with a significant positive relationship between chronic inflammation and Hp in migraine patients (p<0.001).Although no significant differences in attack frequency and average attack duration was detected between the Hp-positive and Hp-negative migraine subgroups. The pain intensity between migraine subgroups exhibited a significant difference being higher in Hp-positive migraine patients (p= 0.044). In addition, in the Hp-positive migraine group, significant differences were observed in attack frequency(day/month), attack intensity(visual analog scale) and average attack duration(hours) at the 8th week post-eradication compared to the pre-eradication period.The attack frequency in the Hp-positive migraine group who have been treated was 10.0 before treatment and 6.0 after treatment(p<0.001). The attack intensity was 8.0 before treatment and 5.0 after treatment(p<0.001). The average attack duration was 5.0 before treatment and 4.0 after treatment(p<0.001).

Conclusion: We conclude that Hp causes more chronic active inflammation in migraine sufferers than in individuals with upper GI symptoms without a history of migraine. In addition, migraine sufferers infected with Hp experienced more severe levels of inflammation compared to those not infected with the bacterium. In Hp-infected migraine patients, the presence of the bacteria may be related to the severity of the pain attacks. Hp eradication therapy may potentially play an important role in headache management in Hp-positive migraineurs with upper GI symptoms in addition to conventional migraine treatments. A positive association was also found between GERD and migraine patients independent of Hp status.

Emotional reactivity profiles and stress coping patterns in migraine: Implications for clinical management

Nevin Günaydın — 2026-06-07

Background & Objective: Migraine is a prevalent and disabling neurological disorder, often accompanied by psychosocial factors such as emotional reactivity and stress-related coping patterns. While stress is a well-established trigger, limited evidence exists regarding how emotional reactivity dimensions and coping styles are related in individuals with migraine. This study examined the associations between emotional reactivity dimensions “sensitivity, arousal/intensity reactivity, and persistence” and stress coping strategies in patients diagnosed with migraine, using a structural equation modeling (SEM) framework.

Methods: A cross-sectional study was conducted with 382 patients meeting ICHD-III diagnostic criteria for migraine. Participants completed the Emotion Reactivity Scale and the Stress Coping Styles Inventory, along with a sociodemographic questionnaire. Data were analyzed using SPSS 26 and AMOS 24. Path analysis was performed to examine the relationships among emotional reactivity dimensions and coping strategies.

Results: Sensitivity was significantly associated with both adaptive coping strategies (self-confident: β = 0.219, p < .001; optimistic: β = 0.284, p < .001) and maladaptive coping (helpless: β = 0.148, p = .007). Arousal/intensity reactivity was negatively associated with optimism (β = −0.301, p < .001) and positively associated with helpless (β = 0.453, p < .001), submissive (β = 0.226, p = .003), and social support–seeking (β = 0.167, p = .031) coping strategies. Persistence was not significantly associated with coping styles. Sociodemographic factors including age, education, income, and marital status were also related to coping strategies.

Conclusion: Overall, higher levels of arousal/intensity reactivity were associated with greater reliance on avoidant and passive coping strategies, whereas sensitivity was related to both constructive and dysfunctional coping patterns. These findings highlight the complex role of emotional reactivity in migraine and underscore the importance of considering emotion regulation and stress management within psychosocial interventions for migraine care.

Greater occipital nerve blockage in patients with chronic migraine complicated by medication overuse

Gökhan Görken — 2026-06-07

Objective: To examine the effects of Greater Occipital Nerve (GON) blockade on attack treatment and emergency department visits in patients with chronic migraine (CM) complicated by medication overuse headache (MOH).

Method: A total of 103 patients aged 18-55 years who presented to our neurology outpatient clinic were prospectively included in our study. Bilateral GON blockade (10 mg 0.5% bupivacaine per session) was administered for 4 sessions at 2-4 week intervals, followed by continued treatment for all patients at 1-2 month intervals for 9 months. A pain diary, Visual Analog Scale (VAS), and Migraine Disability Assessment Scale (MIDAS) scores were assessed at 9-month follow-up.

Results: The mean age of the 103 patients was 37.0 ± 9.8 years, and 79.6% were female. A reduction in monthly headache days to fewer than 5 days was observed in 64.1% of cases. Furthermore, a significant reduction was recorded in analgesic use. Similarly, emergency admission and intramuscular treatment rates, as well as VAS/MIDAS scores, showed a significant decrease (p<0.05).

Conclusion: GON blockade appears to be a promising supportive option for patients with CM complicated by MOH.

Evaluation of auditory startle response in migraine and tension type headache

Buşra Yıldız — 2026-06-07

Objective: This study aimed to investigate the auditory startle response (ASR) in the ictal period of primary headache disorders. ASR may serve as a potential marker of brainstem hypersensitivity to external stimuli.

Methods: The study included patients diagnosed with episodic migraine (EM, n=13), chronic migraine (CM, n=9), chronic tension-type headache (CTTH, n=9), and medication-overuse headache (MOH, n=8) as well as a control group of healthy individuals (n = 23). Headache diagnoses were established in accordance with the International Classification of Headache Disorders, 3rd edition (ICHD-III). ASR measurements were performed in all participants, and in patients, assessments were conducted in ictal period. ASR parameters were compared across all groups.

Results: Total ASR probability was significantly elevated in patients with headache compared to healthy controls. In recordings from the orbicularis oculi muscle, both response duration and area under the curve (AUC) were significantly increased in patients with EM and CM. In contrast, only response duration was prolonged in individuals with CTTH and MOH. The presence of associated symptoms such as photophobia, phonophobia, osmophobia, or allodynia showed no correlation with ASR enhancement.

Conclusion: The results demonstrate ASR hyperactivity during the ictal phase in patients with EM, CM, CTTH and MOH, with the most pronounced changes observed in EM and CM. These findings suggest that ASR alterations are associated with the pain component of headache disorders rather than with accompanying sensory symptoms.

Risk of ischemic and hemorrhagic stroke following migraine: A nationwide retrospective cohort study in South Korea

Chaeyoon Kang — 2026-06-07

Objective: This study examined the association between migraine and the risk of ischemic stroke (IS) and hemorrhagic stroke (HS).

Methods: This retrospective cohort study used data from the Korean National Health Insurance Service (NHIS) and included 13,379 individuals with migraine and 66,895 propensity score–matched controls. The primary outcome was the incidence of IS, and the secondary outcome was HS. Time-stratified Cox proportional hazards models were employed for analysis.

Results: Migraine was associated with an increased risk of IS (incidence rate ratio [IRR], 1.78; 95% confidence interval [CI], 1.62–1.95) and HS (adjusted hazard ratio [aHR], 1.71; 95% CI, 1.35–2.18). The risk of IS peaked within the first two years following migraine diagnosis and remained elevated for up to eight years.

Conclusion: Migraine is independently associated with an increased long-term risk of both IS and HS, particularly among younger individuals and males, underscoring the need for targeted cerebrovascular surveillance.

The relationship between the presence of neuropathic pain and quality of life, oxidative stress, and inflammatory parameters in hemodialysis patients

turgut kültür — 2026-06-07

Background & Objective: Neuropathic pain (NP) is common in hemodialysis patients and severely reduces their quality of life. Diabetes, inflammation, and oxidative stress are factors implicated in the development of NP, regardless of dialysis status. This study explored links between neuropathic pain, oxidative stress, inflammation, and quality of life in hemodialysis patients.

Methods: The study prospectively included 113 HD patients, grouped by Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) score (NP ≥12, control: <12).The groups were compared in terms of oxidative stress (native thiol, total thiol, disulfide, and Ischemia-Modified Albumin (IMA) levels) and inflammatory parameters (Systemic Immune-inflammation Index (SII)). The groups were also compared in terms of the Charlson Comorbidity Index (CCI), quality of life (SF-36), and disease perception (B-IPQ).

Results: The native thiol/total thiol ratio was significantly higher in the NP group; however, disulfide levels, disulfide/native thiol, and disulfide/total thiol ratios were higher in the control group (p<0.05). There was no difference between the groups in terms of other parameters. NP presence was associated with a significant decrease in quality of life in all SF-36 subscales (p<0.05). Thiol/disulfide parameters were identified as independent predictors.

Conclusion: The presence of NP in hemodialysis patients is associated with impaired thiol/disulfide homeostasis, independent of diabetes and inflammation. Oxidative stress may play a dominant role in NP pathogenesis and that thiol/disulfide balance is a more sensitive biomarker compared to IMA.

Clinical and immunomodulatory profiles of satralizumab and rituximab in AQP4-IgG+ NMOSD: A retrospective cohort study

Liu Dan — 2026-06-07

Background & Objective: Seropositive neuromyelitis optica spectrum disorder (NMOSD) is characterized by frequent relapses and substantial disability rates. The efficacy and safety of existing drugs vary. There are relatively few direct comparative studies of satralizumab and rituximab. The objective of this study is to systematically compare the efficacy and immunomodulatory effects of satralizumab and rituximab in patients with NMOSD.

Methods: A retrospective controlled study design was adopted to select 132 NMOSD patients hospitalized at The Second Hospital of Lanzhou University spanning January 2019 to December 2023. After exclusion, 129 cases were included, 3 cases were lost to follow-up, and 4 cases were excluded due to incomplete data. Finally, a total of 122 cases were analyzed and divided into Group A (rituximab treatment, 60 cases) and Group B (satralizumab treatment, 62 cases) according to the treatment plan. The primary observation indicators included Annualized Relapse Rate (ARR), recurrence time, changes in Expanded Disability Status Scale (EDSS) score, changes in AQP4-IgG concentration, Treg and CD20+ cell counts, and the secondary observation indicators included levels of inflammatory factors (IL-6, TNF-α), levels of IgG subclasses (IgG1, IgG3), incidence of adverse events, and quality of life score (SF-36).

Results: Baseline data between the two patient groups were numerically indistinguishable, with the groups being comparable (P>0.05). After treatment, Group B had higher AQP4-IgG concentration, Treg cell count, CD20+ cell count, IgG1, IgG3, and SF-36-GH score than Group A (95%CI: -0.19--0.005, P=0.038; 95%CI: -8.77-- 1.17, P=0.011; 95%CI: -242.42--237.89, P<0.001; 95%CI: -5.00--0.94, P=0.004; 95%CI: -3.80--0.02, P=0.048; 95%CI: -7.98--0.04, P=0.048); and Group B had numerically lower ARR, EDSS score, IL-6, and TNF-α than Group A (95%CI: 0.003-0.09, P=0.035; 95%CI: 0.004-0.7, P=0.047; 95%CI: 0.39- 1.66, P=0.002; 95%CI: 0.13-6.91, P=0.042). Group B had fewer adverse events were observed in the incidence of infusion/injection reactions and infection (95%CI: 1.10-25.63, P=0.023; 95%CI: 0.94- 22.71, P=0.042). The recurrence time in Group B was longer than that in Group A [HR: 1.77 (1.16, 2.72), P=0.006]

Conclusion: In this single-center retrospective cohort of AQP4-IgG+ NMOSD, satralizumab use was associated with lower ARR and EDSS at 18 months than those treated with rituximab, whereas rituximab was associated with greater peripheral CD20+ B-cell depletion. These are unadjusted observational associations and should be interpreted cautiously; prospective randomized studies are needed to confirm comparative effectiveness and safety.

Vision-related quality of life in neuromyelitis optica spectrum disorder: Evidence of subclinical visual dysfunction

Teng Siew Tan — 2026-06-07

Background: Neuromyelitis optica spectrum disorder (NMOSD) is a severe inflammatory demyelinating disorder of the central nervous system that frequently results in permanent neurological disability, most commonly due to recurrent transverse myelitis. Although physical and psychological health-related quality of life in NMOSD has been widely studied, the impact of optic neuritis (ON) on vision-related quality of life (VRQoL) remains underreported.

Methods: This multicenter cross- sectional study assessed VRQoL using the National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) in 52 patients: 30 with prior ON (NMOSD+ON) and 22 without (NMOSD−ON). VFQ- 25 scores were analyzed alongside clinical parameters including best-corrected visual acuity (BCVA), disease duration, and ON history.

Results: NMOSD+ON patients were older (median 43 vs. 33 years; p = 0.02), had longer disease duration (8.5 vs. 4.5 years), and lower BCVA (p = 0.002). NEI VFQ-25 composite scores were significantly lower in the NMOSD+ON group (75.7 vs. 98.3), with consistently reduced scores across all subscales (p<0.001). Notably, NMOSD−ON patients demonstrated subtle reductions in general vision, near tasks, and distance activities, suggesting subclinical optic nerve involvement. Multivariate regression analysis identified BCVA of both the better and worse-seeing eyes as independent predictors of VRQoL, irrespective of ON history.

Conclusions: These findings underscore the sensitivity of NEI VFQ-25 as a patient-reported outcome measure for detecting visual compromise in NMOSD, including subtle deficits in patients without clinically overt ON.

The observation of enlarged perivascular spaces and white matter hyperintensities in patients with type 2 diabetic nephropathy based on MRI

Guang Tan — 2026-06-07

Background & Objective: Diabetic nephropathy (DN) is one of the common complications of diabetes, and cerebral small vessel disease is associated with cognitive deficits and functional impairment. This study aims to explore the correlation between enlarged perivascular spaces (EPVS) and white matter hyperintensities (WMH) with different stages of type 2 DN, and to evaluate the relationship of diabetes- related parameters with EPVS and WMH.

Methods: A total of 213 type 2 diabetic participants with possible DN underwent 3T MRI and laboratory analysis. The participants were grouped according to the urinary albumin-to-creatinine ratios (UACR) or estimated glomerular filtration rate (eGFR), respectively. EPVS number and grade were rated on MRI in the centrum semiovale (CSO-EPVS) and basal ganglia (BG-EPVS). Periventricular and deep WMH (PWMH and DWMH) were also graded on MRI. The logistic regression analysis was performed to evaluate the association of risk factors with EPVS and WMH.

Results: eGFR was associated with the severity of BG-EPVS (p=0.033), DWMH and PWMH (both p<0.001), and UACR was associated with the severity of BG-EPVS (p=0.010) and DWMH (p<0.001). HbA1c (p=0.013 for DWMH, p=0.024 for PWMH), I2/I0 (p=0.032 for BG-EPVS and DWMH, p=0.014 for PWMH) and CysC (p=0.002 for DWMH, p=0.043 for PWMH) showed associations with the severity of WMH.

Conclusions: Our study indicated the close correlation of kidney function related parameters (eGFR and UACR) and cerebral small vessel diseases (mainly EPVS and WMH) in patients with DN. HbA1c, I2/I0 and CysC may be the risk indicators of WMH in this population.

Virtual reality technology for the treatment of mild cognitive impairment: Changes in immune-related genes and alternative splicing and implications for treatment efficacy

Nazuke Yusupu — 2026-06-07

Background: Mild Cognitive Impairment (MCI) is recognized as a critical transitional stage from the preclinical phase of Alzheimer’s Disease (AD) to overt dementia, while AD is a progressive neurodegenerative disorder with limited therapeutic options. Virtual Reality (VR) therapy has emerged as a promising non-pharmacological intervention for cognitive disorders. The purpose of this study was to investigate the molecular mechanisms underlying VR therapy in AD-MCI.

Methods: RNA sequencing was performed on peripheral blood mononuclear cells (PBMCs) from healthy volunteers (C, n=5), AD-MCI patients before VR intervention (ADB, n=5), and after completion of the VR- based Cognitive Rehabilitation Software (VR-CRS) program (ADA, n=3). We conducted differential expression analysis, functional enrichment and trend clustering of genes. Alternative splicing events were also analyzed and co-expression networks were constructed with RNA-binding proteins.

Results: Principal component analysis revealed a distinct shift in the global gene expression profile following VR-CRS intervention. Differential expression analysis identified 421 upregulated and 186 downregulated genes in ADB vs. C, and 165 upregulated and 1002 downregulated genes in ADA vs. ADB. A core set of 251 genes was consistently altered by AD-MCI and modulated by VR-CRS. Functional enrichment highlighted the significant involvement of immune and inflammatory response pathways. Trend clustering pinpointed a key gene cluster (including transcription factors ZFP36, FOS, JUN, FOSB and the mitochondrial gene PMAIP1) that was upregulated in ADB and decreased to normal after VR-CRS. These genes showed significant correlations with immune cell proportions. Furthermore, widespread differential alternative splicing events were observed, affecting genes involved in cell cycle, immune response and neural function (e.g. AMPD2, MALAT1, DDX3X), which were also partially restored by VR-CRS treatment.

Conclusions: VR-CRS intervention is associated with transcriptomic changes in patients with AD-MCI, primarily involving modulation of immune and inflammatory pathways. It also appears to influence alternative splicing patterns. These preliminary findings provide novel molecular insights into the potential mechanisms of VR-CRS, suggesting it may act as a multi-faceted intervention targeting both transcriptional and post-transcriptional networks.

Autophagy in neurodegenerative diseases: A double-edged sword in disease progression and therapy

Xiaojuan Yang — 2026-06-07

Background: Autophagy constitutes a critical catabolic pathway that mediates the degradation and recycling of dysfunctional organelles and cytotoxic protein aggregates. Accumulating evidence indicates its pivotal involvement in the pathogenesis of major neurodegenerative disorders, including Alzheimer’s disease (AD), Parkinson’s disease (PD), Huntington’s disease (HD), and amyotrophic lateral sclerosis (ALS). This study seeks to systematically investigate global research trends and the underlying intellectual structure pertaining to autophagy in the context of neurodegenerative diseases.

Methods: A total of 5,034 articles published over 20 years were analyzed using CiteSpace (version 6.4.1R), VOSviewer (version 1.6.20), bibliometrix (R package), Scimago Graphica(version 1.0.46.0), and Microsoft Office Excel 2021(version 16.48). Analyses included co-citation, keyword evolution, and collaboration networks.

Results: Over the past two decades, the field has experienced robust growth, with a 24.93% annual publication growth rate and over 224,000 cumulative references. China and the United States led in publication output, with significant international cooperation. Authors such as Rubinsztein DC and Nixon RA were highly cited. Influential journals included Autophagy and Journal of Biological Chemistry. Established research areas include autophagy, neurodegenerative diseases, Parkinson’s disease, Alzheimer’s disease, amyotrophic lateral sclerosis, oxidative stress and apoptosis. keywords analysis emphasizes mitophagy, oxidative stress, and neuroinflammation, with a focus on disease-specific mechanisms and cellular microdomains. The autophagy–mitochondria– lysosome axis has gained prominence, highlighting organelle quality control and its role in neuronal survival, paving the way for integrated, stage-specific therapeutic strategies.

Conclusion: Autophagy is now embedded within disease-specific networks, revealing new insights into disease mechanisms and therapeutic strategies. Its dual role in neuroinflammation, both protective and contributory, adds complexity to its involvement in disease progression. Moving forward, research should refine these insights, targeting disease stages and cellular networks to develop more effective therapies.

Cell adhesion molecule L1-like protein regulates neuregulin-ErbB receptor signaling in glioma cells

Wei-jiang Zhao — 2026-06-07

Objective: It was previously demonstrated that the cytokine neuregulin 1 (NRG1) can promote the proliferation of glioma cells by modulating cell adhesion molecule L1-like (CHL1) protein expression in glioma development. However, the role of CHL1 in NRG signaling modulation remains to be elucidated. In the present study, the effects of CHL1 on NRG signaling in three glioma/glioblastoma cell lines were explored mainly by using small interfering RNAs (siRNAs) targeting CHL1.

Methods: SHG44 and U251 glioma, and U-87 MG glioblastoma cells were treated with siRNA targeting CHL1 for 48 h. Then, the protein expression of NRG1-4, and their cognate receptors pErbB2-4 was evaluated by western blot in these cell lines. Immunofluorescence staining was used to evaluate the effect of CHL1 on pErbB2 and pErbB4.

Results: siRNA targeting CHL1 significantly and differentially downregulated the expression of the main NRG subtypes, including NRG1, 2, 3 and 4. Downregulation of CHL1 expression also reduced the level of phosphorylated (p) activated NRG receptors p-ErbB2, 3 and 4.

Conclusions: Overall, these data indicated that CHL1 may contribute to glioma malignancy by upregulating NRG signaling in glioma/glioblastoma cells.

Early institutional experiences of awake craniotomy with tumor removal at Chulabhorn Hospital, Thailand

Chaipatr Setprapha — 2026-06-07

Background & Objective: Brain tumors in eloquent regions pose major surgical challenges due to the high risk of neurological deficits with conventional resection. Awake craniotomy mitigates these risks through intraoperative neurophysiological monitoring that helps preserve eloquent function. Yet its adoption and documentation in Thailand, and Southeast Asia more broadly, remain limited. This study aims to address this gap and support regional advancement and benchmarking of the technique.

Methods: We implemented a structured awake craniotomy program at Chulabhorn Hospital using a standardized asleep–awake–asleep (AAA) protocol with rigid skull fixation, informed in part by training from The Royal Melbourne Hospital.

Results: Eight patients with intracranial tumors in eloquent cortical areas underwent surgery under this protocol. One intraoperative and one postoperative seizure occurred. Motor function was preserved or improved in nearly all cases, with only a single instance of postoperative weakness. Language outcomes were stable in five patients and improved in three. Gross total resection was achieved in five procedures, while three achieved subtotal resections. There was no perioperative mortality, surgical site infection, or need for reoperation.

Conclusions: These findings on one of the few documented series of awake craniotomy in Thailand demonstrate that this technique can be safely introduced and effectively performed within emerging neurosurgical centers in Southeast Asia. Our experience shows that a standardized AAA protocol is both safe and feasible for tumor resection in eloquent brain regions and provides an important foundational step toward expanding the technique and strengthening regional neurosurgical capacity.

Evaluation of relationship between androgen levels and cerebrospinal fluid opening pressure in women diagnosed with idiopathic intracranial hypertension

ARİF SARI — 2026-06-07

Objective: In this study, we evaluated the relationship of plasma and cerebrospinal fluid (CSF) testosterone and dehydroepiandrosterone sulfate (DHEA-S) levels with CSF opening pressure in women diagnosed with idiopathic intracranial hypertension (IIH).

Method: We prospectively evaluated 52 female patients (aged 15-45 years) diagnosed with IIH according to modified Dandy criteria. In the plasma and CSF samples collected simultaneously, testosterone and DHEA-S levels were measured using chemiluminescence microparticle immunoassay (CMIA). The patients were assigned into two groups based on CSF opening pressure. The hormone levels were compared and correlation and ROC analyses were performed.

Results: In the group with high CSF pressure (≥ 40 cmH₂O), the plasma testosterone, plasma DHEA-S and CSF testosterone levels were found to be significantly higher (p<0.05). In addition, strong positive correlations were observed with CSF opening pressure and plasma testosterone (r=0.856), CSF testosterone (r=0.870) and plasma DHEA-S (r=0.915) levels. In the ROC analysis, the cut-off value was determined as ≥ 3.45 nmol/L for plasma testosterone, ≥ 295 µg/dL for plasma DHEA-S and ≥ 0.08 nmol/L for CSF testosterone.

Conclusion: Plasma testosterone and DHEA-S levels showed a significant relationship with CSF opening pressure. These findings suggest that plasma androgen levels can be used as a potential biomarker to predict intracranial pressure in a non-invasive manner.

Clinical and molecular spectrum of TSC1 and TSC2 mutations in pediatric tuberous sclerosis complex: Report of five novel variants

Sevgi Yimenicioglu — 2026-06-07

Background: Tuberous sclerosis complex (TSC) affects multiple systems. We evaluate the patients with TSC clinically in detail and, if possible, make genotype–phenotype correlations in patients with pathogenic variants in the TSC1 and TSC2 genes.

Methods: In this retrospective study, pathogenic germline variants in the TSC1 and TSC2 genes were identified using a combination of direct sequencing and multiplex ligation-dependent probe amplification (MLPA). There were 15 males (53.6%) and 13 females (46.4%).

Results: Twelve patients (42.8%) carried genetic mutations. All detected variants were classified as pathogenic or likely pathogenic, and five variants (41.6%)—four in the TSC1 gene and one in the TSC2 gene—had not been previously reported. Patients were divided into two groups according to the current diagnostic criteria: definite TSC (17 patients) and possible TSC (11 patients). The frequency of cortical tubers, renal cysts, adenoma sebaceum, and definite diagnosis increased with age (p = 0.023, 0.002, 0.02, and 0.013, respectively). Cortical tubers, renal cysts, and angiomyolipomas were observed more frequently in patients with genetic mutations (p = 0.001, 0.002, and <0.001, respectively). Epilepsy was common in patients with intellectual disability (p = 0.03).

Conclusion: Patients with genetic mutations frequently exhibit cortical tubers, renal cysts, and angiomyolipomas. Radiological examinations should be performed repeatedly over time, as cortical tubers, adenoma sebaceum, renal cysts, and definite diagnoses tend to increase with age. In addition, patients with epilepsy should be evaluated for intellectual disability.

Wolf-Hirschhorn syndrome a series of 18 patients: Their clinical characteristics, cytogenetic and molecular findings

Ayşe Burcu Doğan Arı — 2026-06-07

Objective: Wolf–Hirschhorn syndrome (WHS) (#194190) is a well-defined microdeletion syndrome characterized by typical facial findings, prenatal and postnatal growth retardation, hypotonia, microcephaly, intellectual disability, and seizures. Clinical findings vary depending on the size of the deletion. WHSC1, WHSC2, LETM1, CPLX1, CTBP1, PIGG, and FGFRL1 were responsible for the clinical findings. The objective of this study was to describe the clinical, cytogenetic, and molecular characteristics of patients diagnosed with WHS and to contribute to the existing literature by presenting our data.

Methods: This study retrospectively presents the clinical, cytogenetic, and molecular findings of 18 patients.

Results: All the patients had typical facial findings, growth retardation, microcephaly, hypotonia, and intellectual disability. Seizures were present in all patients, except for two. Moreover, 16 patients had thin corpus callosum on cranial magnetic resonance imaging. The diagnosis was confirmed by chromosomal analysis, fluorescence in situ hybridization, and microarray analysis.

Conclusion: Confirmation of the diagnosis is important for increasing clinical awareness, appropriate follow-up, of patients and genetic counseling.

Validation of an early ambulation protocol after transfemoral cerebral angiography: A randomized controlled trial

yueyue he — 2026-06-07

Background: Access-site complications constitute a substantial portion of the morbidity associated with transfemoral cerebral angiography, yet no standardized protocol exists about early ambulation for patients after digital subtraction angiography and practice patterns vary widely. The objective of this study was to validate the efficacy and safety of early ambulation protocol for transfemoral cerebral angiography patients.

Methods: A prospective, two-arm, single-blinded, parallel group, randomized controlled trial was designed enrolling patients undergoing transfemoral cerebral angiography from April, 2023 to February, 2024. The data of demographic and complications, comfort, pain, sleep after digital subtraction angiography were collected and analyzed.

Results: A total of 371 patients were enrolled in this study, 190 patients in intervention group,181 patients in control group. 14 patients (3.77%, 2.11%VS5.52%, p=0.104) met the oozing, 9 patients (2.43%, 1.58%VS3.31%, p=0.327) met the palpable hematoma over the femoral artery. In all cases, there was no further oozing or enlarging hematoma. 15 patients (4.04%, 3.16%VS4.97%, p=0.436) indwelling urinary catheter, 49 patients (13.21%, 12.63%VS13.81%, p=0.761) met difficulty excretion after femoral artery puncture. There was no statistically significant difference in all complications between the two groups. There was no statistically significant difference in comfort score (95.41±10.38 VS 94.13±10.84, p=0.247), pain score (1.35±2.40VS 1.25±2.18, p=0.696) and sleep score (4.04±4.20 VS 3.78±4.26, p=0.566) between the two groups.

Conclusions: Transfemoral cerebral angiography is a common procedure with no clear consensus regarding the early activities. Our results show that early ambulation protocol will not increase the postoperative complications of patients, the score of comfort increased, although no statistically significant.